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Based on observation, documentation review, and staff interview, the Critical Access Hospital (CAH) failed to ensure high/low level glucometer control solutions (used to verify the glucose monitor is working accurately) were dated when opened for the Accu-Chek Inform II glucometer located in the medical/surgical nursing area.

Verifying accuracy of the glucometer requires two glucose control solutions, a high-level solution and a low-level solution. Each glucose control solution contains a known amount of glucose. Staff used these solutions to perform quality control checks to ensure the glucometer worked properly and the blood glucose results were reliable. The use of unstable Accu-Chek Inform II control solutions could potentially provide an inaccurate result of the known amount of either high or low level glucose and would be no longer a reliable way of verifying the glucometer is working accurately. The CAH had a census of 10 inpatients at the time of the survey.

Findings include:

1. Review of manufacturer's information for the Accu-Chek Inform II control solution bottles stated, "...Write the date the bottle was opened on the bottle label. The solution is stable for 3 months from that date..."

2. On 4/27/15 at 11:15 AM during the initial tour of the Nursing unit with Staff A, the Compliance Officer, showed 4 opened bottles of Accu-Chek Inform II control solution bottles at the nurses station ready for use. Observation showed 4 of the 4 bottles lacked an opened date in accordance with the manufacturer's information.

3. During an interview on 4/27/15 at 1:00 PM, Staff A agreed the Accu-Chek Inform II control solutions were not dated when staff opened the bottles, however, all of the bottles should be dated when opened. The facility did not have a policy regarding this procedure.

Based on review of Critical Access Hospital (CAH) documents and staff interview the Administrative staff failed to have a system in place to to ensure the CAH had a current dated agreement with the local utility companies and others for the provisions of emergency sources of critical utilities such as water and fuel. The CAH had a census of 10 inpatients at the time of the survey.

Failure to ensure the CAH had a dated agreement with an emergency source to supply fuel and water to the CAH in the event of an emergency could potentially result in the inability to provide care for the CAH in-patients and people that arrived for emergency care.

Findings Include:

1. Review of the CAH documents, lacked a current dated agreement with an outside entity to supply fuel and water for the CAH to continue to operate and provide care for the in-patients and people that arrived at the CAH for emergency care in the event of an emergency.

2. During an interview on 4/28/15 at 4:00 PM, Staff H, the Maintenance Manager acknowledged the CAH lacked a current dated agreement with an emergency source for water and fuel.

I. Based on review of policies, procedures, manufacturer's information, observation, and staff interviews, the Critical Access Hospital (CAH) failed to ensure proper cleaning of the blood glucose monitors in 1 of 2 areas performing fingerstick blood sugars per manufacturer's recommendations and facility policy (Medical/Surgical unit). The CAH had a census of 10 inpatients at the time of the survey.

Failure to clean patient care equipment as directed by the manufacturer could potentially place patients at risk for exposure to infections and blood borne pathogens.

Findings Include:

1. Observation on 4/27/15 at 11:15 AM on the medical/surgical unit revealed Staff B, Registered Nurse (RN) used the Accu-Chek Inform II blood glucose monitoring machine to perform a blood glucose test for a patient in room 106. Staff B completed the patient's blood glucose test, without cleaning and disinfecting the blood glucose monitoring machine, Staff B returned the blood glucose monitoring machine in the carry case. Staff B then entered patient room 127, used the potentially contaminated blood glucose monitoring machine and performed a blood glucose test on the patient in room 127. Again, Staff B without cleaning and disinfecting the blood glucose monitoring machine returned the potentially contaminated blood glucose machine in the carry case. Staff B failed to clean and disinfect the blood glucose monitoring machine between each patient use.

2. Review of CAH policy titled "Accu-check, Blood Glucose Monitoring" revised 8/14, revealed in part... "Clean meter using sani-wipe. Clean around slots and openings, (do not get moisture in slots or openings), and entire surface. Dry with gauze. Place in dock charging station." The policy did not specify how often to clean the machine.

Review of the manufacturer's guidelines for the Accu-Chek Inform II blood glucose monitoring system, dated 2013 revealed in part... "12. Clean and disinfect between each patient use following standard precautions and cleaning/disinfecting procedures."

3. During an interview on 4/27/15 at 11:40 AM, Staff B reported she cleaned the blood glucose monitoring machine 4 times a day. She did not clean the blood glucose monitoring machine after using it on each patient. Staff B reported she cleaned the blood glucose monitoring machine after using on isolation patients.

During an interview on 4/27/15 at 1:00 PM, Staff A, Chief Nursing Officer reported staff are to clean the blood glucose monitoring machines after using it on each patient.



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II. Based on review of documents, observation, and staff interview the Critical Access Hospital (CAH) Dietary Department failed to clean the fans blowing on the clean dishes in the dish room. The CAH administrative staff identified 10 inpatients at the time of the survey.

Failure to ensure all fans in the Dietary Department were cleaned and free from any debris that could be blown onto the clean dishes could potentially result in contamination of the clean dishes used for the patient's meals.

Findings include:

1. Observation on 4/27/15 at 1:00 PM, with Staff G, the Dietary Manager revealed 2 fans in the dish room were blowing on the clean dishes used for meals served to inpatients. Both fans contained a moderate amount of a build-up of black-brown debris.

2. Review of the document titled, monthly 2015 cleaning schedule revealed maintenance staff cleaned the kitchen fans on 4/7/2015.

3. During an interview on 4/27/15 at 1:30 PM, Staff G revealed the fans were used to assist with drying of the dishes.

During an interview on 4/27/14 at 4:00 PM, with Staff F, the Compliance Officer, revealed the facility lacked a policy for the cleaning of the kitchen fans.

Based on record review and staff interview the Critical Access Hospital (CAH) failed to limit badge access to Health Information Management (HIM) to authorized staff. The CAH management identified a inpatient census of 10 at the time of the survey.

Failure to limit access to the medical records, HIM could potentially result in access to confidential patient information by unauthorized staff without a need to know.

Findings Include:

1. Review of the User Group for HIM Badge Access document, dated 4/28/15, showed 69 CAH staff had badge access to the HIM department. Staff included on this list were doctors, housekeepers, nurses, admission clerks, therapy, lab, dietary, schedulers, and administration.

Review of the policy titled, "Secure filing of Medical Records" dated 1/02 included in part "... It is the policy of the CAH to ensure that the medical records are maintained in a secure and confidential manner. Areas housing health information shall be restricted to authorized personnel..."

2. During an interview on 4/28/15 at 2:00 PM, Staff I, the HIM/Privacy Officer revealed a lack of knowledge regarding staff members with badge access to the HIM department and who authorized the staff access.

Based on document review and staff interview, the Critical Access Hospital (CAH) failed to delineate privileges for 1 (of 1) Ophthalmology Technician, Staff E, who was not an employee of the hospital, to assist with ophthalmology surgical procedures. Staff E assisted with 5 ophthalmology surgical procedures a month provided by an associated practitioner, Practitioner A.

Failure of the CAH to verify the staff was qualified to provide surgical assistance for the Practitioner during procedures could result in patients receiving surgical interventions from unqualified professionals.

Findings include:

1. Review of the Operating Room Log on 4/28/15 at 9:15 AM with Staff C, the Operating Room Manager revealed Staff E provided surgical assistance for Practitioner A during ophthalmology surgical interventions for patients. Staff E assisted with an average of 5 surgical procedures a month completed by Practitioner A.

Review of the Surgical Privileges Manual on 4/28/15 lacked documentation that showed Staff E had surgical privileges to provide assistance during surgical procedures with Practitioner A.

2. During an interview on 4/28/15 at 9:15 AM, Staff C, Operating Room Manager acknowledged Staff E lacked surgical privileges to provide assistance during surgical procedures with Practitioner A.

During an interview on 4/28/15 at 9:30 AM, with Staff D, the Organizational Performance Coordinator reported Staff E did not have privileges to assist Practitioner A with surgical procedures. Staff D reported she did not know Staff E required surgical privileges by the hospital to provide assistance with surgical procedures at the CAH.

Based on review of policies, documents, and staff interview, the Critical Access Hospital (CAH) failed to ensure 2 of 2 Radiologist, selected for review, received outside entity peer review performed by the Network Hospital to evaluate the appropriateness and diagnosis and treatment furnished to patients at the CAH in accordance with the CAH's agreement with the Network Hospital (Physicians B and C). The CAH credentialed 6 active physicians, 71 courtesy physicians, and 31 courtesy physicians were Radiologists.

Failure to ensure all medical staff members received outside entity peer review affects the CAH's ability to ensure physicians provide quality care to the patients at the CAH.

Findings include:

1. Review of CAH policy titled "Medical Staff Peer Review", dated 1/2014, revealed in part, ". . . It is the Policy of Marengo Memorial Hospital (MMH) to monitor clinical performance and identify opportunities for practice and performance improvement of individual practitioners who hold membership/privileges to promote safe and quality health care for its patients. . . The medical staff will use the provider-specific peer review results in making its recommendations to the hospital regarding the credentialing and privileging process and, as appropriate, in its performance improvement activities. . . ."

Review of the Network Agreement, dated August 1, 2012, revealed in part, ". . . [Network Hospital] shall assist Hospital [CAH] in reviewing the quality and appropriateness of the diagnoses and treatment furnished by Hospital's physicians and other practitioners for purposes of assisting Hospital in carrying out the requirements of its quality assurance plan. . . ."

Review of CAH documentation on 4/28/15 at 2:30 PM, revealed the facility failed to ensure the CAH received completed peer review by the Network Hospital specific for the services provided to patients at the CAH for Physicians B and C. Physician B read 227 radiology exams for the CAH patients in the last 12 months. Physician C read 965 radiology exams for the CAH patients in the last 12 months.

2. During an interview on 4/28/15 at 2:30 PM, Staff F, Director of Organizational Performance acknowledged the CAH had not received completed peer review by the Network Hospital specific for the services provided to patients at the CAH for Physicians B and C for the medical staff to use the provider-specific results during the physician's credentialing and privileging process.